3.Kirk Heilbrun — Direct (Part 1)

KIRK HEILBRUN: Good morning.

KIRK HEILBRUN: I do.

KIRK HEILBRUN: Good morning, sir.

KIRK HEILBRUN: Yes. My name is Kirk Heilbrun. That's spelled K-I-R-K and then H-E-I-L-B-R-U-N.

KIRK HEILBRUN: I'm a psychologist. I am in the Department of Psychology at Drexel University in Philadelphia. And, as part of that, I run two clinics. One is a clinic where I conduct psychological evaluations for... Thank you, sir. For courts and attorneys, and the other is what we call the Reentry Project, where we provide assessment and treatment services to individuals who are either returning from federal prison or under the jurisdiction of a federal mental health court, or have been exonerated following a false conviction.

KIRK HEILBRUN: Yes, I do. I'm a forensic psychologist, and that means that I take the application of clinical psychology, and I apply it to legal proceedings in criminal and civil matters.

KIRK HEILBRUN: Yes, I can. I received a doctoral degree from the University of Texas at Austin in 1980. And I, as part of that, I was received training in various sorts of assessment and treatment and therapy and research and things like that. And then as, also as part of that, I was involved in a full-time internship between 1979 and 1980 at the University of Texas Health Science Center at San Antonio.

KIRK HEILBRUN: I did. I received...

KIRK HEILBRUN: From 1981 to 1982, I did a postdoctoral fellowship in the applications of psychology to crime and criminal justice.

KIRK HEILBRUN: That involved a full-time exposure to clinical work in correctional and forensic populations, and also a thorough exposure to the clinical and research literature on assessment and interventions with these individuals.

KIRK HEILBRUN: I am licensed in the state of Pennsylvania, and I'm also part of something called PSYPACT, which allows people licensed in one state to practice on a temporary basis in another state.

KIRK HEILBRUN: I'm board-certified with the American Board of Professional Psychology, which is the older, oldest, and most rigorous kind of board certification agency, organization in the country.

KIRK HEILBRUN: Yes. I'm also board-certified in forensic psychology with the American Board of Professional Psychology.

KIRK HEILBRUN: I do. Between 1981, 1982 and 1991, I was first a staff psychologist, then a chief psychologist at the Florida State Hospital in Chattahoochee, Florida. And then between 1991 and 1994, I served as the clinical director of the forensic unit at Central State Hospital in Petersburg, Virginia. And at that time I was also serving as an associate professor in the Department of Psychiatry at the Medical College of Virginia in Richmond. And as a part of these positions, I had responsibilities for providing assessment and treatment services myself, and also for supervising such services provided by others.

KIRK HEILBRUN: I could. I teach graduate and undergraduate courses in forensic assessment and law and psychology. And as part of the clinic that I mentioned at, a moment ago, I conduct forensic evaluations at the request of judges and attorneys, and I supervise individuals who are providing services to the individuals who are either coming back to the community from prison or under the jurisdiction of a federal mental health court, or who are leaving prison having been exonerated following a false conviction. And finally I conduct research and supervise students who are working in psychology and law areas.

KIRK HEILBRUN: I have. Over the course of my career, I've published about 240 articles, chapters, and books in the areas of aggression and violence, juveniles, mentally disordered adult offenders, forensic assessment, ethics, and malingering and deception. And two of my interests, two of those interests that are particularly applicable to the present case are risk assessment, which helps us understand the influences contributing to violent behavior. And also forensic mental health assessment, where we consider the important principles and steps that are connected with psychological and psychiatric evaluations in legal contexts such as criminal or civil proceedings.

KIRK HEILBRUN: Yes. Over the past 15 years, I've presented about 50 lectures and workshops in the areas of forensic assessment, risk assessment, treatment, sexual offenders, and ethics.

KIRK HEILBRUN: No. I would call them perhaps someone who's being evaluated or an evaluee or something like that. They're not a patient because the role of therapist in treating a patient is different from the role of a psychologist or psychiatrist in conducting a forensic mental health assessment. They're different in a number of different ways. But basically, what we try to do as a forensic evaluator is we try our best to conduct a thorough evaluation, in which we are out there and trying our best to be accurate and just come up with something that is as true and accurate as we can possibly make it in terms of evaluating the questions that we're asked. When we're working as a therapist, basically we're working to help somebody improve in their—in various kinds of difficulties that they're having in life, symptoms, problems, and that sort of thing. And the two can conflict sometimes because, as a therapist, I just wanna do my best to help somebody. As a forensic evaluator, I wanna do my best to be as accurate and open and thorough as possible, even if it doesn't necessarily help someone.

KIRK HEILBRUN: I would not, no. If I were asked to do that, I would explain that those are two different roles, that there is very likely a conflict of interest that could arise if I try to do both, and I would refer whoever requested it to another individual to conduct the evaluation.

KIRK HEILBRUN: I have. Over the course of my career, I've testified about 330 times, with adults and juveniles. The issues have included things like transfer and sentencing, competence to stand trial, mental state at the time of the offense, civil commitment, and personal injury. I've testified on behalf of both the defense and the prosecution, and I've been qualified as an expert in juvenile, criminal, and civil litigation in both state and federal court. And I estimate that over the course of my career, I have conducted—about 75% of the time I've conducted an evaluation and testified on behalf of the defense. And the remaining 25% have been conducted and have testified on behalf of the prosecution or by order of the court.

KIRK HEILBRUN: Yes, that happens with the prosecutor, and it also happens with the defense. And it's just something that we have to be able to do if we're in the profession of forensic psychology because if we are—try to be thorough and accurate and impartial, then sometimes the results will favor whoever asked us to conduct the evaluation, and sometimes they won't. And what they have to hear, if my findings don't favor them, is that they're probably not gonna wanna use it.

KIRK HEILBRUN: There is. That's something that's been discussed particularly in the last 10 or 15 years, and there are a number of different kinds of biases that the field has paid particular attention to, potentially, over the last 20 years or so. And retention bias is the bias that is a part of what we can experience when we want to, or incline to favor the side that asked us to conduct the evaluation. And that's an important consideration, and I'm aware of it, and I try to guard against it as much as possible by talking with others, getting multiple sources of information, and a variety of other ways of doing that.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: I have not specialized in that way. Most of my forensic evaluation experience has been with criminal and juvenile matters, and they have often included alleged crimes of violence. But I haven't specialized in any particular kind of mental or emotional disorder, any particular kind of crime, anything like that.

KIRK HEILBRUN: I am, yes.

KIRK HEILBRUN: Yes, I do. Among the biases I talked about a minute ago, there's something called confirmation bias. And basically, that's if you make up your mind earlier or incline toward one particular diagnosis or anything like that, then there can be a real problem because when you get conflicting information, that is information that's not consistent with that decision that you've made or leaned toward early on, then the problem becomes, you pay attention to the information that's consistent with it, and you stay away from the information that isn't. And so in some ways, for me, not specializing gives me an advantage because what I can do is come in and not be inclined toward any particular diagnosis or possible answer to a particular set of questions or a particular hypothesis or anything like that. What I can do is do my best to look at the different possibilities, and when there's evidence favoring one or supporting one, I'm inclined toward that. And when there's not, then I set it aside.

KIRK HEILBRUN: I have, yes. I served as the chair of my department at Drexel for 15 years, and I've also served as the president of two national organizations, the two that are most strongly associated with forensic psychology in this country. One is the American Psychology Law Society, and the other is the American Board of Forensic Psychology.

KIRK HEILBRUN: I was, yes.

KIRK HEILBRUN: One, one of the things it entailed is doing my best to review a lot of information, to meet with Ms. Clancy in an interview, to speak with her in particular about what happened around the time of the alleged offense, to conduct collateral interviews with other individuals and review a wide range of documents. And so I have been reviewing documents since January of 2025. I had the opportunity to meet with Ms. Clancy in April of this year, 2026, and at that time, spent three days with her, along with Dr. Avram Mack. One of those days, which was video recorded, we talked about her background and a lot of information like that. The second day, where I met with her myself and did not video that because some of these psychological tests are private, and they should not be videoed. So we did some psychological testing during that second day, and then on the third day, back with the video, back with Dr. Mack, we talked with Ms.

KIRK HEILBRUN: Clancy about the things that she was thinking and feeling and doing around the time of the alleged offense. And so I mentioned that I reviewed records. I've got a report sitting in front of me, and those records are spelled out over four pages, so I'm not gonna run through the whole list with you. But those records did include things like cellphone records, the defense expert forensic psychiatric evaluation reports by Dr. Resnick and Dr. Spinelli, some Department of Children and Family records, digital forensic records, including texts and information that was provided by—

KIRK HEILBRUN: The watch that she wore, the Apple Watch, and the phone, a variety of medical records, police investigative records, police interviews with many people, and grand jury proceedings, as well as surveillance footage of the Clancy family going to various places, Museum of Science visit, Cape Codder, CV's, that sort of thing.

KIRK HEILBRUN: About 180 hours prior to coming to Plymouth. So most of that was spent in reviewing records. About ten and a half hours was spent in meeting with Ms. Clancy and doing the testing, and then another hour and a half was spent in collateral interviews.

KIRK HEILBRUN: I interviewed her former husband, Patrick Clancy, and his mother, Ms. Clancy's mother-in-law, Sue Clancy.

KIRK HEILBRUN: Not her mother. I did request to interview her sister, and I think she decided against that.

KIRK HEILBRUN: Correct.

KIRK HEILBRUN: Well, that's something that I do sometimes, conduct a joint interview. That's done in training context, for example, a fair amount. And in this case, many of the questions that we were gonna ask her, a large number of the questions that we're gonna ask her about her background and her history were gonna be similar. So we were able to conduct those, ask those questions in a way and save some time, keep her from having to go through and ask and answer them twice. Then the third day, again, many of the questions that we were gonna ask had to do with her thinking, feeling, and behavior leading up to the time of January 24th, and basically, it involves kind of a step-by-step process, going very slowly, getting a lot of detail. And w- I expected, we expected that many of those questions, sort of step-by-step detail, were going to be things that we would be able to work on, or there were gonna be things that we could ask twice, or we could ask once and see it on the video.

KIRK HEILBRUN: We did not, no. Although we were interviewing her together on two days, we took that information, and we each independently came up with our own report, our own review of that information, our own analysis of what it meant, and so on. So, no. We wrote separate reports. We actually did not agree on the diagnosis.

KIRK HEILBRUN: I did, yes.

KIRK HEILBRUN: Yeah. So one of the psychological tests, which I'll talk about a little bit later, is called the Adverse Childhood Experiences Measure, and that's something that asks an individual whether they went through what we would call adverse experiences or traumatic experiences as a child and an adolescent. And there are 10 of them, and if you have four or more of them, that puts you at higher risk for different kinds of adverse outcomes as an adult. She did not endorse any of those. So on the ACES questionnaire she had a zero, which really goes to the question that you ask of whether she had adverse or traumatic experiences as a child.

KIRK HEILBRUN: She did not report any, and there were any number of individuals who were asked similar questions about her childhood and her adolescence, and they all said basically, no, she did not.

KIRK HEILBRUN: Yes, I can.

KIRK HEILBRUN: So it was about 12 weeks after her son Callan was born, and she was feeling very anxious and sometimes depressed about having to leave him when he went back to work. There were two reasons for that. One is that she had felt anxious about leaving her children on a number of occasions and with the previous kids. But the second reason was she was breastfeeding, and Callan was not taking the bottle. And so she was worried if she went back to work—she worked as a labor and delivery nurse on the night shifts—and she was worried that if she left Callan home and he woke up in the night and wouldn't take the bottle, there would be a problem. And so that was what got her particularly anxious. And what happened was she looked, searched for a psychiatrist, found one, Dr. Jennifer Tufts, in September, and went to Dr. Tufts and got a prescription for Zoloft to... She wanted to reduce her anxiety somewhat. And she didn't begin taking it immediately. She was a little bit worried about the impact that it might have on the breast milk. But sometime in October, she began taking the Zoloft, and things started getting very difficult at that point.

KIRK HEILBRUN: I did. Both of those. And from, I guess you could say the records because a number of people had talked about that, including her husband, Patrick. And I also got some of that information from him as well during the collateral interview.

KIRK HEILBRUN: What was happening toward the end of his 12-week paternity leave is that she was getting more anxious. When she started in mid-October taking the Zoloft, she immediately began to have some difficulty. The anxiety did not get better. In fact, it got worse. There were some symptoms of depression. She immediately started having some really difficult insomnia, and felt a lot of stress, and so on. And so...

KIRK HEILBRUN: In October and moving into November, she had hoped to return to work and planned to return to work, but it was not going to work out for her because her symptoms were really difficult. So in the middle of November, she texted her mother-in-law, Sue Clancy, who was at work, also a nurse, and she was in the emergency room at South Shore Hospital. She felt unwell. She was having problems sleeping. She had a racing heart. She had lost some of her appetite. Continuing into November, she was struggling with anxiety, severe insomnia, palpitations. She was just having a lot of difficulty with the thought of leaving the baby, racing thoughts, feeling overwhelmed, and things like that. So moving further into November, into late November, she was just having real difficulty with sleep disruption, and she had concerns all along, starting in mid-October, about the impact of the medications. It was her thought that the medications were giving her some of these adverse reactions, because it was really difficult for her to look at this and say, "I wanted to get some improvement in the anxiety, and I did not. Instead, it got worse." And so late in November, she was still having a lot of trouble sleeping. She thought that she was close to what she called the end of her rope. She was feeling off and disconnected and sort of like a zombie, and she began to report panic symptoms, concerns about being addicted or dependent on the benzodiazepines. So kind of disoriented and forgetful and disconnected from her body. So she was having a lot of difficulty with what she thought were the medication that was resulting in this kind of impact. And then into December, it was not getting better.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: We're still on number two.

KIRK HEILBRUN: But I'm also slipping in a little bit of number three as I answer number two.

KIRK HEILBRUN: Yes. Around this time, late November, early December, she began to experience what she called horrible intrusive thoughts, and those thoughts were about harming herself, potentially. And as she continued to experience these kinds of thoughts later into December and January, they would occasionally be about harming the children. But for the most part, particularly early on, these were thoughts about possible suicide and harming herself, and the way she described it is, "These thoughts would just pop into my head," and they included things like, "Your brain is damaged. You need to kill yourself." Now, the way she described these is they were not auditory hallucinations. Instead, they were her own thoughts. They were intrusive and unwelcome, but they were not auditory hallucinations, and that's important because if she had been hearing a voice like you're hearing my voice right now, it comes from outside of your head, and that's a different kind of a symptom than having thoughts, even unwelcome and intrusive thoughts, that are in your head. If it's coming from outside, that is very likely a psychotic symptom. And if it's a psychotic symptom, then that has different implications for what's wrong with you, as opposed to something that is unwelcome and intrusive, but inside your own head.

KIRK HEILBRUN: Yes. That's right. It was important because of what I just said, that I ask her the question, "When you were experiencing these thoughts, were they like your own thoughts or were they like auditory hallucinations?" And she said, "They were like my own thoughts." And she made it clear that they were unwelcome and intrusive, "But they were like my own thoughts." And she didn't get to talking about experiencing auditory hallucinations, as I will talk about a little bit later, until January 24th.

KIRK HEILBRUN: And so she continued to have real difficulty with various kinds of problems. She had lost about 15 pounds, not intending to. She was having tremors and sweating and GI symptoms and sadness, severe depression, that sort of thing. As she described it, feeling numb and zombie-like were her words, again in December. And then by middle December, it was getting very difficult for her as she talked about it. Her sleep was getting a little bit better, but she was continuing to have significant symptoms of depression, things like hopelessness and the loss of capacity for pleasure and things like that. She described her experience on December 14- December 15th of 2022 as one of her worst days.

KIRK HEILBRUN: She went to... Her husband took her to Mass General that day, and she did not stay very long, but it was one of those things that was really difficult. The symptoms were, as she saw it, pretty bad. And then on December 20th, she went to a hospital called Women and Infants in Rhode Island, and they had a day program for postpartum individuals having difficulties. And they said that they weren't gonna take her, that she didn't meet their criteria for the postpartum program. Generally, that was because they said that she looked like she was having general anxiety symptoms and depressive disorders, but not so much the postpartum necessarily. And—

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: Not quite, Judge, but almost.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: So she was not going to remain in Women and Infants, and the next step that she took was hospitalization at McLean.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: I was, yes.

KIRK HEILBRUN: They did, yes.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: No. What I saw is that they were back to being treated according to the plan and the medication and so on. But she was back to being treated, discussing with Dr. Tufts what the best implications were for treatment.

KIRK HEILBRUN: Yes. She was admitted to McLean on January 1st of 2023, and what got her there was suicidal thinking. That was very difficult for her. That was a very difficult time to experience that sort of thing. And so she went into McLean on January 1st. And their admission documentation listed postpartum depression and major depressive disorder, which they described as recurrent and mild. While she was in McLean, what she reported as her primary concern was insomnia. And she said that while she was hospitalized, it actually made her more anxious than being at home. And when she was asked about the suicidal impulses and thoughts, she said that she would not commit suicide because of her children and her mother. So she had some... They asked about reasons for living, among other things, and those were some of the ones that she cited.

KIRK HEILBRUN: Yes, sometimes it's called a protective factor.

KIRK HEILBRUN: Yes, would keep you from doing something like that.

KIRK HEILBRUN: So she stayed at McLean for five days, and she was documented as not having safety concerns and at minimal risk for returning to the community by January 3rd. She described her mood there as numb, but she denied things like delusions or hallucinations or suicidal thoughts that were continuing or homicidal thinking. And at the time she was discharged on the 5th of January, she was described as cooperative and pleasant, with no psychosis, no suicidal or homicidal thinking. And she said, when I was asking her about it, that when she left McLean, she had a—what she described as a small shred of hope after discharge because she was off of medication, Seroquel, which she thought was causing her a lot of trouble. And but the intrusive suicidal thoughts returned, she said, within a week or so following her discharge from McLean.

KIRK HEILBRUN: Yes, we are.

KIRK HEILBRUN: Well, I have ... I think I've combined two and three as I've talked about this, because one of the things about this is after she started taking the medication in October, the Zoloft, she had—the anxiety didn't get better. She had difficulty with, great difficulty with insomnia, and she said she was numb. She felt like a zombie. It wasn't something that she was able to see any improvement in. In fact, she thought, "I was getting a lot worse." And so basically the ... what she thought is that the symptoms that she was experiencing following taking the medication that was prescribed beginning in October, she said the symptoms were getting worse, particularly, particularly a new symptom, which was insomnia.

KIRK HEILBRUN: Yes, and I won't take nearly as long in talking about that because one of the things that she thought was happening when she began taking that medication in October is that it was j- ... The medication itself was far from making the anxiety better. It was making it worse and keeping her from sleeping and it was, she thought, making it difficult for her to ... Y- she thought that the medication was actually making it a real problem for her to sleep, to feel. She felt emotionally numb and that sort of thing. And so accompanying the bad insomnia with the apparent adverse responses producing the insomnia and other things was a real problem for her as she saw it, and it's one of the things that she continued to emphasize to providers, whether it was Dr. Tufts or Ms. Jollotta, a nurse practitioner. She said, basically, "I think this is ... I think these medications are making me worse." But one of the things, moving on to number five there, one of the things she also said is that she was focusing on making the anxiety, helping the anxiety get better through medication. There was a little bit of counseling going on with Ms. Jollotta, but one of the things that she did not really have was, say, a cognitive behavioral therapist or something like that to help her work through the problems. She thought that medication was going to try to help, and she ... And it really did. It was something that she focused on a good deal.

KIRK HEILBRUN: Yes, all of those things.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: Excuse me just one moment. Over the course of the time that she was going through these experiences between mid-October and late January, she'd had a lot of providers offer a lot of diagnoses, and there were a lot of complicating considerations. So among some of the diagnoses that she'd been given were adjustment disorder with anxiety and depression, generalized anxiety disorder, major depressive disorder, bipolar disorder, bipolar disorder II, postpartum depression, postpartum psychosis, post-traumatic stress disorder. That last one was not before January of 2023, but it's something that she has right now. And in addition to those diagnoses, which sort of implies that she has a disorder and she has symptoms, there were complicating factors. She had psychotropic medication with apparent adverse reaction. She had serious sleep deprivation over a three-month period. She had, between five and eight months after the birth of her third child. She had anxiety about returning to work in the fall of '22. She was worried about leaving her baby for work. And he was not taking the bottle. And the other thing which was important for her is she was always someone who was... She was into exercise, and she stopped exercising sometime in October when she started having these adverse reactions. But it's one of these things that she... It was a real difficult thing for her to handle when she couldn't do the running or the yoga or the Peloton or other things that she used to keep her anxiety managed.

KIRK HEILBRUN: Yes. She was trying that, yes.

KIRK HEILBRUN: Well, if it works. It does work for some people, and they use it effectively over the course of their lives, particularly if they have some anxiety that might not fully need treatment, but it's something that might interfere with your life a little bit.

KIRK HEILBRUN: Well, if we could move on to the next slide, please.

KIRK HEILBRUN: So I ended up with a diagnosis, making a diagnosis of bipolar II disorder, which is a slightly less—not slightly—it's a less severe form of bipolar disorder.

KIRK HEILBRUN: Because bipolar, as I said, is a more severe kind of diagnosis. It's more noticeable. And if you had a bipolar diagnosis, then I would wanna see something that looks, that clearly and definitely looks like a manic episode, and I did not see any evidence of that before January 24th of 2023.

KIRK HEILBRUN: Well, there was some indication in the records that some people thought it was manic. I did not see it that way. She did not describe, when I asked her, whether... She did not describe that as a manic episode. She didn't think it was. And when I talked to Patrick Clancy, he said he didn't think it was either. And basically, it was cleaning out the garage and getting a lot of stuff into 20 trash bags and so on. But one of the things he said is, you know, they were both working hard, but it wasn't all her out there putting stuff in 20 trash bags and he wasn't a part of it. He said he was definitely a part of it.

KIRK HEILBRUN: Yes, that's right.

KIRK HEILBRUN: Well, that's something where it's less clear that it's manic, and that's one of the things that inclined me toward bipolar II, is I just did not see signs that were clearly manic episodes. But it looked like something that it possibly could have been a less serious or less severe manic episode.

KIRK HEILBRUN: It's a disorder that typically comes on in adulthood. It's not something that you have as a kid or even for the most part as an adolescent. It's something that you start to show the signs of when you are in your 20s or 30s.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: Well, one of the things that I wanted to say about number eight is that I wasn't called up here just to make a diagnosis or talk about symptoms. This is a criminal responsibility evaluation, and one of the things that I take a look at very carefully when I'm doing something like this is what's the standard for criminal responsibility in the jurisdiction. Now, I'm aware that the court will instruct the jury about the standard and how you apply it and so on, but my understanding of the standard for criminal responsibility in Massachusetts is that a person is not criminally responsible if at the time of the offense they suffered from a mental disease or defect, and as a result, lacked substantial capacity either to appreciate the criminality or wrongfulness of their conduct, or to conform their conduct to the requirements of the law. So there were really three parts. There really are three parts to that criminal responsibility standard. The first is mental disease or defect, and that's one of the reasons why I've paid so much attention to the symptoms and when they began and things like that. But the other thing that I try to do is take those symptoms and see how they affect somebody, in this case Ms. Clancy's, capacity for knowing that something like this was illegal or wrong. Or how they affected her capacity for conforming her conduct to the requirements of the law, which I think of as kind of controlling her behavior.

KIRK HEILBRUN: It is, yes. And it's something that I put on page one of my report because I always try to do that to try to make it as clear as I can that this is something I'm paying attention to throughout the entire evaluation.

KIRK HEILBRUN: It is, yes.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: Yes, I can. On the MMPI, which I spoke about, first, and this was, of course, three and a half years after the alleged offense. So it's gonna describe... Much of it is gonna describe her thinking and feeling and behavior in April of 2026 rather than January of 2023. But it's something that I—that's always a challenge when you try to reconstruct what happened some time ago. And so some of these tests were administered from the standpoint of, what was it like for you back then? But the MMPI was delivered in terms of how you're doing right now. And she, on the response style scales that I talked about earlier, she showed a slight tendency to under-report, to deny unusual experiences, although she, she did that in a way that was pretty sophisticated. She's a bright woman. And so given this, we kinda take into account a little bit the fact that she might be under-reporting a little bit in terms of what's really wrong with her.

KIRK HEILBRUN: However, there are a number of what we call clinical scales on this test, and she was not elevated on any of them, meaning that she's not actively symptomatic in many areas or in great distress in certain ways. But there was one scale that is elevated, and that is the suicide and death ideation scale, thinking about suicide and death. And I should say that Ms. Clancy has been on one-to-one suicide precautions, which is the highest level of precautions that a hospital can take, since she came to Tewksbury. This is a very long time to be on that kind of precautions, and what it says to me is that she was at risk for suicide. She remains at risk for suicide, and so she still is. The adverse childhood experience questionnaire I mentioned earlier, basically it's a measure of whether somebody is reporting experiencing, as a child or adolescent, adverse or traumatic events, and she was not. So she had a zero on that. There were two measures of suicide intent. One is called Beck's Suicide Intent Scale, and the other is called the Columbia-Suicide Severity Rating Scale. And I can sum up those results very quickly by saying that

KIRK HEILBRUN: When she responded to one of them as she would have if she'd been filling it out in January of 2023, what it suggested is that this was a very serious suicide attempt at that time. And when she responded to both of them as she feels right now, she also was indicating that she remains at high risk for suicide, and hence the one-to-one supervision for three and a half years. The Brief Symptom Inventory is something where you ask people about a number of possible symptoms that they've been experiencing within the last month or so. Gave it to her under two circumstances. One is, "How are you doing right now?" That is around April of this year, and the other was, "How were you doing in January of 2023?"

KIRK HEILBRUN: Her description of how she was doing in January of 2023 is that she endorsed feeling blue or still extremely depressed, feeling no interest in things, thoughts of death or dying, feeling hopeless about the future, feeling very self-conscious with others, and the idea that something is wrong with her mind. She thought depression, suspiciousness, memory problems, problems with attention and concentration, and things like she was having trouble concentrating, so she'd be cooking, for instance, and she'd forget what step she was on. So most of these are consistent with symptoms of depression. And so I thought that they were good indications that she was endorsing feelings of depression, although she was improving somewhat from her December feelings.

KIRK HEILBRUN: The—something called the Obsessional Beliefs Questionnaire has three scales.

KIRK HEILBRUN: The other thing about the why question is it could well be something that is valuable to know when we're thinking about whether she understood that something was wrong or when she was thinking about whether she could conform her conduct to the requirements of the law or control herself. The why question seemed important. So if I could have the next slide.

KIRK HEILBRUN: I did, yes, which is on this slide.

KIRK HEILBRUN: Now, in a minute, I'm gonna talk about the evidence that I saw supporting each of those, but I will tell you right now, in advance of talking about that, that most of the evidence that I saw, I saw supported the second one and not the first.

KIRK HEILBRUN: Yes.

KIRK HEILBRUN: The first was, that's what she said. I asked her that question, and that's the way she explained it happened. She said, sometime on the afternoon of January 24th, 2023, that she heard a voice, and the voice said, "This is your last chance. You have to kill the kids so you can kill yourself." If she actually heard a voice like that, that would be evidence of psychosis being experienced and what we call command hallucinations, where the voice is instructing her to do something. There were some other possible things that made me think that it could be a severe mental illness that she was experiencing, and two in particular. One was thinking that others might know her thoughts. Now, this is something that is a symptom of psychosis called thought broadcasting if it's experienced in a certain way. In thought broadcasting, if I'm experiencing that, I literally have the idea that if I'm thinking it, you can hear what I'm saying, just as if I were putting it on the television or podcast or a movie or whatever. It's just coming out that way. I asked her about that, and she said... And other people asked her about that too, and she said it was not thought broadcasting, but these were very vivid thoughts. And she thought that it might be that people could hear them, as vivid and strong as they were. The second possible symptom is that thinking police might take her children. Now, some of the records, in some of the records, I saw people saying, "Well, this looks like a paranoid delusion to me." And I will tell you that it didn't look either paranoid or like a delusion to me, and here's why. I'm a healthcare professional, and that means that in Pennsylvania and every other state I know, I'm a—

KIRK HEILBRUN: I'm a mandated reporter. If someone tells me in therapy or in an assessment that they think that a child is going to be injured or severely hurt or that might happen, then I'm required by law to contact Childline in Pennsylvania. Ms. Clancy is a labor and delivery nurse. She's a healthcare professional as well.

KIRK HEILBRUN: And so it's one of those things where if she had thought, if she had said to a psychiatrist, psychologist, anyone providing treatment, that she thought she was experiencing ideas like she might harm her kids, she would know, as a mandated reporter, that they would, were legally required to report that. Now, that might not mean that the police would literally come and take her kids away, but it would mean that there would be an investigation. She would have to answer questions, and it might be that for a period of time she would be separated from the children.

KIRK HEILBRUN: y-yes, that's okay.

KIRK HEILBRUN: Yes. That's the way it's defined.

KIRK HEILBRUN: Well, that was what I was trying to say, is that it is not a false belief. It's quite possible that it could come to pass.

KIRK HEILBRUN: Yes. The other point there at the bottom is that it's appealing as an explanation because it could explain acts that seem so out of character for her. You don't have to get complicated at all. It's just, “I had a psychotic episode. I heard a voice. The voice told me to do something terrible. I did it.”

KIRK HEILBRUN: I did, yes.

KIRK HEILBRUN: One of the, one of the reasons—well, the first bullet point here—is that the way she described this as happening is that she heard a voice that she'd never heard before, experienced an hallucination, and she's never experienced it since. But she only experienced it for the 18 minutes or so that it took to kill the children. And to put it mildly, that would be a very, very unusual pattern or manifestation of how this kind of thing comes about. Very unusual. I've been doing this kind of evaluation for many, many years, and I'm always very careful when someone tells me that they experienced a symptom only during the course of committing an offense. Uh—

KIRK HEILBRUN: Well, because it provides a convenient way of lessening your own culpability. I mean, it's always possible, but as I said, I find it very, very rare. Whereas an explanation for why somebody did something, somebody might look at that and say, "It's a convenient way of somebody looks at me, and it's— I don't have the same culpability that I would otherwise."

KIRK HEILBRUN: There was some discussion of whether this was postpartum. And so she was about eight months away from having given birth to Cowen, her youngest child. And most of the explanations, or most of the sources of authority, like DSM-5 or the Cleveland Clinic, will point to maybe one month after birth or two months after birth or something like that. But the farther away you get time-wise from the birth, the less likely it is, under those kinds of authority, to be postpartum. Now, it could be something else, and there were certainly some things that I saw that were symptoms of depression and other sorts of things that she experienced in January. But it was, given the time, it was less likely, I thought, to be postpartum. Then the next bullet was inconsistencies in her account. To me, when asked about this, she said the voice said, "This is your last chance. You have to kill the kids so you can kill yourself." And it just kept repeating that, and only that, and only that for about 18 minutes, or the duration of the time it took to do this. There were other times, though. For instance, when she was in the hospital after this happened and was talking to a psychiatric attending. When she said that the voice had said other things, for example, "The children will suffer without you," or, "You have to take the kids with you," or things like that. So, inconsistency is important because it suggests inaccuracy. In other words, which version is accurate? Is it the first? Is it the second? Is it neither? I mean, here it couldn't be both, because she said, "I only heard this," to some people she said that, and then, "I heard this plus this," to other people she said that. So-

KIRK HEILBRUN: The more inconsistency there is-

KIRK HEILBRUN: You might have to repeat the question.

KIRK HEILBRUN: What I would say is the more inconsistency there is, the more problematic I find it to take any one particular account and say, "This is the accurate one."

KIRK HEILBRUN: There is some research that's been conducted on malingered hallucinations, which are accounts of hallucinations that are exaggerated or fabricated. And I found it useful to look at those, look at that research and see what it suggested and kind of lay it out there in terms of the way she described it. So, some research suggests that one consideration is whether the voices are internal or external, whether they're coming from your own thoughts or whether they're coming from outside of your head. And Ms. Clancy perceived this voice as external, which is more consistent with genuine hallucinations.

KIRK HEILBRUN: However, command hallucinations are often, in about eighty-eight percent of individuals reporting them by one count, accompanied by a related delusion. Ms. Clancy did not report any accompanied delusions. So thus far you've got one point for genuine and one point for possible exaggerated. Then there's frequency and control. Genuine psychotic hallucinations are more often intermittent than constant. They'll come, and they'll go. You'll hear it, stop hearing it. You'll hear it again, stop hearing it, and this can extend over a period of time. Ms. Clancy, in this instance, reported that the voice was constant for eighteen to twenty minutes, and then it stopped. It had not been experienced before, and it has not been experienced since. And she also did not report having any control over the voice or over her actions in response to the voice. Then the next item is content. So genuine hallucinations are often familiar, use both genders, and are clear rather than vague. Ms. Clancy described this voice as clear, but it was unfamiliar, and it was a single male voice. So that was sort of mixed.

KIRK HEILBRUN: I'm not counting it as one direction or another. And then finally, reaction and coping. Individuals who experience hallucinations like this often try to reduce their influence by different, in different ways. Could be praying, could be listening to music. And while those who inaccurately report the experience of such hallucinations often do not describe coping mechanisms. And Ms. Clancy didn't report any attempt to stop the voice or distract herself from it or what have you. So there were about three points on which her account more closely resembled exaggerated or fabricated hallucinations. One where it looked more genuine and one that was kind of mixed.

KIRK HEILBRUN: Yes. When we try to appraise through testing or specialized measures something that looks like malingering or exaggeration, the way we typically do it as psychologists who develop the measures is it looks like somebody who is going to take a shotgun approach. They're gonna say, "Unusual things are wrong, and strange things are wrong, and many things are wrong," and things like that. If you do that, we're pretty good at picking up that shotgun approach to malingering. But if I ask you a bunch of questions, and you answer them almost entirely in a genuine way, that you're being as accurate as you can, except with one exception, when I ask you about one experience or one symptom and you exaggerate or fabricate that, it's very— we can't pick that up through our testing. So what we have to do instead is, we have to kinda develop our ideas about how it might have been experienced, what it was consistent with, what the disorder is. We take a broader approach, which is what I've tried to do in talking about this.

KIRK HEILBRUN: Yes. I'm gonna start with a question of thoughts or hallucinations. I've already said that I found the account of hallucinations to be, as she described it, it would be very, very unusual to experience it that way, never having—not before, not since—constantly for eighteen minutes. However, if this was a thought, an unwelcome, intrusive thought, but still a thought, that's basically, "This is your last chance. You have to kill the kids so you can kill yourself," then that would be consistent with thoughts that she'd been experiencing for some time. She'd been having thoughts about harming herself, that she was... It was gonna be very difficult for her to do this in a way that was, that made sense. She was...

KIRK HEILBRUN: She was experiencing thoughts about hurting herself because her brain might have been damaged. She was experiencing thoughts about hurting the kids. She was experiencing all sorts of unwelcome thoughts. If that were the case on January twenty-fourth, if these were thoughts—then that would be consistent with what she'd been experiencing for months before. So that was something that made more sense to me, that rather than an auditory hallucination, it would've been an unwelcome intrusive thought. The next bullet is her response to her husband's question, "What did you do?" So when he got home around 6:00 PM on January 24th, and the house was quiet, and he went in, thought people might have been playing hide and seek with him, called downstairs, didn't get an answer, called upstairs, didn't get an answer. Went upstairs, found the bedroom door locked, unlocked it with his key, went in, saw some blood there, saw the window was open, ran downstairs, and he saw his wife Lindsay lying there semi-conscious. And he said his first question was, "What did you do?"

KIRK HEILBRUN: And her response was, "I tried to kill myself." Now, I thought that if she had actually experienced this command hallucination, that she might have said something like, "I did what I had to do," or, "I did what the voice said," or something like that. But no, she said, "I tried to kill myself." And I... This is consistent with my looking at this and starting from the perspective of this is a serious, highly lethal suicide attempt, and that's the way to understand it. And then the last bullet point has to do with the recovery of memories. So when she regained consciousness that night in the hospital, one of the things she said is that she wasn't able to remember what had happened.

KIRK HEILBRUN: And she was informed of it, but if this had been a genuine memory loss, then human memory is funny. And one of the things that happens is that when you're trying to remember something that actually happened, things can interfere with that.

KIRK HEILBRUN: Things that you read, things that you're told, other sorts of things like that. So it would've been hard to understand how she would recover that memory accurately, including the particular memory of the command auditory hallucination and what it said.

KIRK HEILBRUN: Yeah, I'm gonna pass on that one and go to the next slide.

KIRK HEILBRUN: Well, there were some additional inconsistencies in terms of whether she knew that... When I asked her whether she was aware that it was illegal or immoral, she said, basically, "I wasn't thinking about this at all. No, no thoughts, no decisions, none of that. It was just all action." One of the things that Dr. Resnick wrote in his report is that she was intellectually aware that it was wrong or illegal, but not morally. And what she said to me is that, "I just don't think it... I wasn't thinking about that at all. I didn't know any of that."

KIRK HEILBRUN: Yeah. Altruistic filicide is a term that's used that means killing your kids out of love, not because you're trying to be cruel or for material gain or because you want them out of your lives or any of that. But killing them out of love so that you could, basically, they wouldn't have to suffer, so you could prevent their suffering. And what she did, I thought, was begin with what I said a minute ago was a highly lethal and very serious suicide attempt.

KIRK HEILBRUN: It was preceded by months of thoughts and impulses about, "You should harm yourself, you should kill yourself, your brain is damaged," that sort of thing. And that, I think, is the beginning of the way to understand what happened that day. The second point is that, as I've said before, she didn't like to leave her children. Whether that was for date night or school or going back to work or anything, she did not like to leave her children. And if she had taken her own life, then her children would have been without her, and she thought that they would suffer. And she'd been having these thoughts both about herself and about her children over a several-month period. And the other thing that I will say is that she was in pain. She was suffering. She was doing a little bit better than she had been before she went into McLean, but she was still in pain.

KIRK HEILBRUN: She was suffering. I think she was even desperate, and that is something that is often characterized as people who try to take their own life. They're in pain, they're suffering, and they're trying to put a stop to it. And I think when she decided at some point that she was gonna put a stop to it, then she had to answer the question of what to do about the kids, and she didn't wanna leave them, and she was convinced that they would be... They would suffer without her.

KIRK HEILBRUN: There was. One of the things that she said when asked about what happened is that in the course of strangling each child, she said, "Go to God, baby. Go to God."

KIRK HEILBRUN: And that was part of her expectation, that she and the children would be together in heaven with God. She was raised as a Catholic, and this, as I understand Catholic considerations, that's not necessarily what happens. But, but when I ask her about that, when I said, "Isn't suicide a mortal sin?"